Treatment Value Form

There are two reasons we need you to fill out the Treatment Value Form:

1) Filling out and returning the Treatment Value Form to your referral coordinator will help us estimate

the total value of dental care as well as the types of services being donated by dentists across Ohio.

2) At the end of each calendar year, you will receive information from us acknowledging your

contribution to the program. This is subject to you proving the information to us as each case is


CLICK HERE to download the Treatment Value Form.